JRNYS Self Injection Consent Form

I, the undersigned patient, hereby acknowledge that I have been informed about the option of self-injecting medication prescribed by my healthcare provider. I understand that self-injection involves certain risks, responsibilities, and requirements for safe administration and I understand if I have any uncertainty I am able to book a virtual meeting with a JRNYS nurse through my patient portal.

By clicking below, I acknowledge that I have read and understood the information provided and agree to follow the guidelines outlined herein.

Responsibilities and Risks:

  • Proper Administration: I understand that it is my responsibility to administer the prescribed medication following the provided instructions accurately. Any errors in administration may affect the efficacy of the medication.

  • Hygiene and Sanitation: I acknowledge the importance of practicing proper hygiene before and during the injection process to reduce the risk of infections. I will clean the injection site as directed and use a new, sterile needle for each injection.

  • Reporting Adverse Reactions: I agree to promptly report any adverse reactions or unexpected side effects to my healthcare provider or the company. This includes any discomfort, redness, swelling, or other symptoms that may occur at the injection site.

  • Storage: I will store the medication as instructed, adhering to temperature requirements and guidelines provided by my healthcare provider and the medication's packaging.

  • Emergency Contacts: I will keep emergency contact information readily available in case of any complications, adverse reactions, or uncertainties during the self-injection process.

Release of Liability:

I understand that there are inherent risks associated with self-injection, including but not limited to infections, allergic reactions, incorrect administration, and other unforeseen complications. By clicking below, I release and hold harmless [Company Name], its employees, officers, directors, and representatives from any and all claims, liabilities, damages, or injuries that may arise from my self-injection activities.


I agree to indemnify and defend JRNYS Wellness LLC from any claims, demands, or actions arising out of or in connection with my self-injection activities, including but not limited to claims for negligence, injury, or breach of any terms outlined in this consent form.